Originally posted by Tim Murphy on NYMAG.com
Gabriel and his friends like to go dancing at places in Chelsea and Hell’s Kitchen like Viva and Pacha. One night last winter, they ended up at a downtown club hosting a circuit party, a huge gay rave with throbbing, industrial house music. The theme was leather and S&M, and Gabriel* wore a singlet. He’s usually the least interested in drinking of the group—he’s the responsible planner—but as the night wore on, he wound up becoming very drunk and very high and making out with lots of men. “I was feeling the fantasy of it all,” he says. A couple he vaguely knew grabbed him. They wanted to do more, insistently. Gabriel resisted at first and then, he says, decided to just give in to the spirit of the evening. It felt, at the time, freeing and hedonistic.
But he hadn’t been wearing a condom when they had sex, and in the morning, he woke up wanting nothing more than to regain control over that moment. Gabriel is a 32-year-old real-estate broker. He had tested negative for HIV the last time he’d been to a clinic. Terrified that might change, he went to Callen-Lorde, a health clinic in Chelsea, where he was placed on a 28-day course of a full HIV-medication regimen. When taken within three days of exposure, it dramatically reduces the chances of infection—something like the morning-after pill for HIV. Gabriel didn’t react well to the course: He felt nauseous and drained the whole time.
He never wanted to go through that again—neither the physical or the psychological anguish. So Gabriel got a prescription from his doctor for Truvada. Truvada is a ten-year-old HIV-treatment pill that, in 2012, quietly became the first drug to be approved by the FDA for a new use: to prevent HIV infection. The drug has the potential to dramatically alter the sexual behavior—and psychology—of a generation. When taken every day, it’s been shown in a major study to be up to 99 percent effective. For Gabriel, it was like switching to birth control instead of Plan B.
Several months after starting the drug, Gabriel says it’s allowed him to be bolder and more unapologetic in his desires, to have the kind of joyfully promiscuous, liberated sex that men enjoyed with one another in the decade or so after the Stonewall riots brought gay life out from the shadows and before the AIDS crisis shrouded it in new, darker ones.
For some men, Truvada’s new use seems just as revolutionary for sex as it is for medicine. “I’m not scared of sex for the first time in my life, ever. That’s been an adrenaline rush,” says Damon L. Jacobs, 43, a therapist who has chronicled his own experience with the drug on Facebook so enthusiastically that some assume Gilead, the drug’s manufacturer, must be paying him. (It’s not, say both he and Gilead.)
“I stayed the night with a guy I knew, whom I believe to be HIV-negative,” he tells me. “We passed out, too drunk to fuck.” In the morning, they tried again, without a condom. “He was getting close to coming,” Jacobs relates, “and he said, ‘Do you want me to pull out?’ and I said, ‘No.’ I thought, I want this experience. I deserve this.”
For the past several years, the conversation about gay life has been, to a large degree, a conversation about gay marriage. This summer—on social media, on Fire Island, at the Christopher Street pier, and in certain cohorts around the country—what many gay men are talking about among themselves is Truvada. And what’s surprising them is how fraught the conversation can be. For some, like Jacobs, the advent of this drug is nothing short of miraculous, freeing bodies and minds. For doctors, public-health officials, and politicians, it is a highly promising tool for stopping the spread of HIV.
But for others, a drug that can alleviate so much anxiety around sex is itself a source of concern. They worry that Truvada will invite men to have as much condomless sex as they want, which could lead to a rise in diseases like syphilis. Or they fret that not everyone will take it as religiously as they ought to, reducing its effectiveness and maybe even creating resistance to the drug if those users later become HIV-positive and need it for treatment. And just as the birth-control pill caused single women in the sixties to wonder whether they’d be seen as “sluts” and to internalize that real and imagined shame, some gay men wonder how Truvada will play in the straight world; it sends a strikingly different message from the one in the “Sunday Styles” wedding announcements.
Other gay men worry that the very existence of such a drug is a kind of betrayal: of those who’ve died in the epidemic; of fealty to the condom, an object alternately evoking fear and resilience, hot sex and safe-sex fatigue; and of a mind-set of sexual prudence that has governed gay-male life since the early ’80s. Even after treatments for HIV made it a manageable disease for many, gay men have absorbed the message that a latex sheath is all that stands between them and the abyss. Meaning not only HIV infection but everything it implies: loss of self-control and personal dignity, abdication of civic responsibility.
Given that tape loop playing in the collective gay-male head, it’s hard to tell whether the argument the gay community is having with itself about Truvadais with the medical facts on the ground or with the very real demons of history: What are gay men scared of?
Many of my HIV-negative friends are on Truvada, but I didn’t know until I asked, and they’d speak to me only if I withheld names. The number of prescriptions is growing: “Last summer was crickets,” says Dr. Demetre C. Daskalakis, the head of HIV services at Mount Sinai Hospital, who played a leading advisory role in getting Truvada FDA-approved for PrEP (short for “pre-exposure prophylaxis,” the medical term for the function Truvada is performing, often used interchangeably with the drug’s name).
Nathan, a 24-year-old hairdresser friend of Gabriel’s who had initially told him the dance-floor slipup probably wasn’t a big deal, sought out Truvada around the time Gabriel did. The man who is now Nathan’s boyfriend—an older, wealthy guy with a Chelsea penthouse—told him to go on it after Nathan had condom-free sex with someone who had said “I’m fine.” Later, the guy divulged that he’d meant HIV-positive but undetectable. (HIV-positive people on regular medication suppress HIV in their blood to levels that don’t even show up on tests, rendering them nearly uninfectious.)
“It’s taken away the taboo of barebacking being a naughty thing,” says Nathan. But, he adds, “now that I’m on it, I’m buying condoms. I don’t want to be one of the guys who’s like, ‘I’m on PrEP, so come over and find me blindfolded and fuck me bareback.’ ”
Some are taking Truvada to do just that—behave without inhibitions. These are people who claim for themselves the epithet, found on T-shirts and in Instagram captions these days, “Truvada whore.” But for others it’s a simpler question, leading them to have the same (mostly) condom-protected sex they’ve always had, only for once in their lives without dread. For the generation of gay men who came of age post-AIDS, anxiety has essentially preceded lust as a first response to thoughts of sex. Sarit Golub, a Hunter College psychology professor, is leading a study at Callen-Lorde that indicates that half of gay men think of HIV all or most of the time during sex. “That, to me, is a psychological tragedy,” she says.
Over coffee and pie at the Blue Stove in Williamsburg not long ago, Adam, 33, a writer and filmmaker I know, mentions that he is exactly the same age as the pandemic.
“The terror was at its height when I was coming of age, postpuberty,” he says. “The message from TV shows that was drummed into us as gay boys was that we could get this disease and die and make our parents very sad. I developed this intense fear when I was having sex with someone and not even doing anything risky. I’d still freak out the next day. What if I gave a blow job to someone and his pre-cum had HIV in it?”
When Adam and I met up, he’d taken his first dose of Truvada the day before. He felt fatigued, but he’d also underslept, so he wasn’t sure it was the drug. The night before, he’d invited over a regular hookup who has told him he’s HIV-negative. “I had wanted him to cum in my mouth,” Adam says, “but I knew that the PrEP doesn’t take full effect for seven days.”
Matthew, another friend of Nathan’s, who works in tech, went on PrEP for extra protection, too. Twice he’s had a condom break. He’s a little older—48—and says he’s watched close friends who’ve been HIV-positive for years struggle with the disease and the meds.
Gabriel, Nathan, and Matthew all say they’ve had no side effects so far. They get labs done every three months to make sure they are still HIV- and STD-free, and twice a year doctors check that their kidneys are okay. (Truvada has been linked to mild kidney damage in a small percentage of people who take it as part of their HIV-treatment regimen.) But that fear of the unknown has kept their friend Lorenzo, a 23-year-old M.B.A. student and go-go dancer, from seeking a Truvada prescription. “I’d rather let them be the lab rats and wait a few years,” he says. “I’m very sex-positive, but … a condom is a wall. It keeps me away from you.”
That, to him, is a good thing.
Researchers suspected HIV drugs could work preventively well before Truvada went to market a decade ago for its original purpose. (Truvada, like all HIV medication, works by disabling the steps the virus takes to hijack human cells.) When the FDA approved Truvada’s use as a prophylactic, the drug company that produces it showed surprising restraint, given the potential size of the new market. Gilead, for which the drug has been a multibillion-dollar blockbuster in treating HIV-positive patients, instead gives money to various nonprofits in support of education and to raise awareness about PrEP. The company says, through a spokesperson, that Truvada is “an important public-health intervention and not a commercial opportunity.” Gilead also has a program to make Truvada available to eligible patients with no health insurance or with unaffordable co-pays.
But some HIV activists feel that Gilead is quietly funding a surge in HIV-negative takers of Truvada—whose list price is about $1,300 a month—while not having to take flak from PrEP opponents for implicitly promoting condomless sex. “If they came out advertising it, they would’ve been attacked,” says Sean Strub, the 56-year-old HIV-positive founder of Poz, the magazine for people affected by HIV and AIDS.
Gilead’s approach seems to be working. At the end of June, during Pride weekend, Governor Cuomo, who has made gay rights a strategic part of his platform, said he wanted to make wider access to the drug part of a new effort to eradicate the AIDS epidemic in the state by 2020. Daniel O’Connell, the state’s HIV-initiatives czar, told me New York expects to put out a public-information campaign about it by year’s end, which will be the first of its kind for PrEP.
Most insurers—both private and public, such as Medicaid—have covered the cost of Truvada-for-PrEP (as they generally do once drugs are FDA-approved for specific uses), and the potentially controversial issue has flown under the public radar. Some bloggers have wondered if the Supreme Court’s Hobby Lobby ruling, which says that private employers can block contraceptive coverage for workers on the grounds of religious belief, might lead some bosses to block Truvada reimbursement on their plans.
Truvada is for everyone at risk of getting HIV, both men and women. But PrEP has been studied in and discussed largely among gay men because the highest HIV rates remain stubbornly within that group, especially among young gay men of color. In 2010, the Centers for Disease Control reported that 20 percent of U.S. gay men had HIV, compared with about .3 percent of the total population. Nearly half didn’t know it—an ignorance that rendered them highly infectious. In 2012, the agency reported that HIV rates in gay men between ages 13 and 24 rose 22 percent in recent years. In an independent analysis of that data, a top researcher projected that if HIV infections continue at current rates, half of young gay men will have HIV by age 50. Cuomo’s stated goal, then, is very ambitious.
Truvada doesn’t, of course, protect against other STDs. Especially for those who were around at the dawn of AIDS, when a mystery microbe appeared out of nowhere, there’s a fear that reverting to pre-condom habits might be tempting fate again. “Mother Nature’s a bitch,” Dr. Martin Markowitz, a veteran of the Aaron Diamond AIDS Research Center, told me. “Don’t underestimate her.”
The idea of prep can be especially fraught for older gay men, particularly HIV-positive ones. Larry Kramer, now 79, in poor health and HIV-positive since the 1980s, has been the most prominent voice projecting contempt and bafflement. In a May New York Times article about the HBO version of his 1985 play The Normal Heart, he was quoted as saying, “Anybody who voluntarily takes an antiviral every day has got to have rocks in their heads. There’s something to me cowardly about taking Truvada instead of using a condom. You’re taking a drug that is poison to you, and it has lessened your energy to fight, to get involved, to do anything.”
PrEP advocates exploded, saying, in part, that Kramer was grossly exaggerating the toxicity of Truvada. (Side effects in HIV-negative takers seem limited so far. Most often, that can mean an initial few weeks of mild nausea and diarrhea—though, as with any new treatment, only time will tell if preventive Truvada has long-term effects.) Andrew Sullivan, who is HIV-positive, wrote on his blog in response: “Imagine a scene [in the play] when someone rushes into a [Gay Men’s Health Crisis, which Kramer helped found in 1981] meeting and declares that there’s now a pill that will make you immune to HIV if you take it once a day. Would Larry seriously have said that anyone who then took it had ‘rocks in their heads’? I think of how it might have saved me.” Michael Lucas, the gay-porn mogul who recently switched from being an ardent condom advocate to a PrEP-taker who now allows bareback sex in his films, wrote on the Out-magazine blog: “Larry Kramer is a hero in many ways, but this time he’s fighting on the wrong side of history.”
Less cantankerous HIV-positive veterans than Kramer also seem to have their misgivings. In a talk this winter at the Strand bookstore to promote his new memoir, Body Counts, Strub, the Poz founder, said of PrEP, “Rather than giving [HIV-negative people] the life skills teaching them how to be healthy about their sexuality … the idea [is unbelievable] that we are going to put tens of millions of gay men on PrEP and bankrupt the economy to spray people with Raid.” (He later clarified that he supports it as an available individual choice.)
Another HIV longtimer—a Chelsea store manager named Steve, 58, diagnosed in 1996—tells me frankly that, though he supports Truvada usage in theory, it mostly just pisses him off on a visceral level.
“I was at the Eagle a couple months ago,” he says, referring to the West Chelsea leather bar, “and this hot little muscly Latin guy told me that he was on PrEP and that I could fuck him raw. Boom, he just said it so easily.” Steve has lost many people he loved to AIDS. He finds even the effervescent celebrations of Gay Pride tough to witness. “I want people to understand why they’re able to take this right now,” he says. “It’s on the backs of people who have died and suffered. All that needs to be learned and honored.”
Walter Armstrong, 57, is an ACT UP veteran who also lost many friends to AIDS. (He is HIV-negative himself.) “AIDS as a huge crisis for middle-class gay men ended in the ’90s,” he says, “but I don’t think I’m the only gay man in my generation who will never get over it.” Still, he hopes PrEP makes condoms obsolete. “There, I said it!” he says, raising his voice. “There’s something really ugly about how some older gay men who’ve lived through AIDS say to younger guys, ‘After all we’ve been through, I can’t believe you would take PrEP and risk your life for sex.’ When I consider all we’ve been through, I can’t believe anyone wouldn’t take it—or at least think about it.”
But old community habits are hard to give up. Photographer and videographer Michael Wakefield, 51 and HIV-negative, has been hosting condom-only sex parties for 20 years. “I’ve seen him literally pull guys off each other if they weren’t using condoms and throw them out of the party,” says Daskalakis, who has often worked alongside Wakefield to offer health access, such as meningitis vaccines, at the venues. “I’ve actually eroticized condoms,” Wakefield tells me. “They mean that something exciting is going to happen. Someone’s about to get fucked.
“But I feel like I’m becoming a dinosaur about condoms.”
In my late 20s and early 30s, after having careful, anxious sex throughout the ’90s, I went through a period of depression and addiction. It’s not that I consciously wanted to have bareback sex, but I did want to get to the point where I wasn’t thinking about condoms and HIV and risk all the time and I could lose myself. Drugs got me there.
I became HIV-positive 14 years ago this summer. By then, with protease therapy available, I wasn’t afraid that I would die from the disease. But I also felt ashamed, damaged even, as though I had somehow betrayed a personal and even a community moral code. Among sympathetic straight people and most gay men, the first wave of men to get HIV in the 1980s got a pass, because nobody knew it was out there or how to prevent it. I was part of the second wave of the infected, those who “should have known better.”
But as the aughts wore on, many of my 30-something friends also became HIV-positive. Not all, by any means, but at least one every few months. Sometimes they’d been struggling with depression and substance abuse, but sometimes they’d just gotten very unlucky. We knew we would have to find a way to access these expensive medications for the rest of our lives.
Worse than that was the knowledge that in the gay sexual pecking order, we were now second-class citizens. Sure, some HIV-negative guys would be fine with us, and there was no shortage of great HIV-positive men to have sex with. But we would always be faced with that choice: withhold our status and feel bad about it, or disclose it and wait for either acceptance or rejection (or, often, a highly confusing mix of the two).
We’d have been good candidates for PrEP.
It is not particularly hard for an employed, insured gay man in a big American city to hear about and obtain Truvada. That’s not the case for much of the group that potentially needs it the most: African-American gay and bisexual males between 13 and 24, who, in 2010, accounted for twice as many estimated new HIV infections as their white or Hispanic counterparts.
Christopher Street and its adjacent piers have long been a hangout for gay and trans kids of color. I spent a few days there this summer, asking people I met what they knew and thought about PrEP. In some ways, they weren’t very different from the older guys I talked to about it in Chelsea and Hell’s Kitchen bars: One of them would know about Truvada, might even be on it, via a health agency like the Harlem Prevention Center, while the others had no idea. Many simply said that they didn’t believe me that such a pill existed, that I had bad information.
“Young black gay men have been very resistant to the idea of PrEP,” I was told beforehand by Steven-Emmanuel Martinez, 25, who is Afro-Latino and has done lots of PrEP outreach in his job at the AVAC, which does vaccine advocacy work. (Progress on the vaccine front, in case you’re wondering? Slow, in a word.) “I plan to go on PrEP myself even though I have very safe sex,” he’d said. “I want guys to trust that I am telling them about it not just because I’m getting paid to, but because I’m experiencing it. For many guys, it just sounds too good to be true.”
On a hot afternoon, I sit on the piers with a group of friends. All are either unemployed or have low-wage jobs, wondering how they’ll kill time this summer. They all tell me they are HIV-negative and that they’ve been tested. Alec, baby-faced at 21 and the most talkative, has heard of PrEP—he’d even passed over a chance to be in a PrEP study, he says, but now he wants to look back into it. “I see why people would do it. Women use birth control. Why should gay men be afraid to use something? People are not always going to protect themselves. They might be escorting.”
“My school offered me to be in a PrEP study, too,” his Afroed friend Alonzo, 22, replies. He hadn’t gone for it.
W., 23, who wears a Chicago Blackhawks hat cocked on his head, is quiet. “This doesn’t interest me,” he says uneasily. He says he’s a virgin. Alonzo says he has sex only twice a year: “I don’t trust nobody.”
But they all agree that they worry about getting HIV. “A lot,” says Alonzo. They are also aware that HIV rates are especially high for men like them. “You could probably just breathe down here and get it,” says Alec, gesturing around the piers.
Rudolph, who is 20, says that he’d learned from the (defunct) gay black TV series Noah’s Arc the alarming mid-aughts CDC statistic that 46 percent of black gay men have HIV. “My grandmother has it,” he says. “You know what makes me angry? There is a cure out there, and they are holding it back. They put AIDS here for a reason.”
Alec says I can call him for a follow-up talk. I learn that he’d flunked out of college and was living with his grandmother in Harlem. And then, after we chat for a bit, he says, “Okay, I’m gonna get really honest with you.” He is an escort, picking up johns in the Village. He uses the money to buy either name-brand clothes for himself or groceries for his grandma. He tested HIV-positive in late 2012 and is on treatment. He has a hard time remembering to take his meds, which he gets through Medicaid, because he drinks and gets high every day.
“I feel like a fool,” he says. “Like I’m in a category, a box. This is what society expected of me. I could’ve protected myself, but I let this happen.”
The target of subtle Truvada promotion is often the HIV-negative gay man in a relationship with an HIV-positive one. Several experts have told me they think it’s redundant for an HIV-negative guy in a mixed-status relation-ship to go on PrEP if his partner is undetectable. But it’s a lot less controversial than targeting someone interested in having unprotected sex with multiple partners.
On a drizzly midweek afternoon, I walk a few blocks through Bushwick to visit Leo Herrera and Michael Beard, who met over the hookup app Scruff amid the frigid misery of last winter. Herrera, 33 and HIV-negative, is a filmmaker and LGBT activist, slight and lean. Beard, 37 and HIV-positive, is a tattooed writer, video editor, and bartender with full cheeks. Herrera is the high-speed lead talker, while Beard gently fills in the blanks. Sitting in Beard’s snug kitchen, his cat Chuck wending his way around their legs, they tell me how, on a freezing night, Herrera invited Beard over for a dinner of Brussels sprouts, sausage, and red wine and, at the end, asked if he wanted to stay over.
“I said I felt fine with it going either way,” says Beard.
“He was being coy,” says Herrera.
“No, I really meant it!” says Beard.
Beard spent the night. He’d told Herrera about his HIV status over dinner (he tested positive in 2011, after condomless sex with a guy who didn’t realize his own positive status), about how he was getting his meds through ADAP, the federal-state assistance program for people with HIV/AIDS. Leo was okay with the news.
They ended up taking baths together all winter long. But it was only in March, when they were both in New Orleans for Mardi Gras, that they fell in love. “I realized,” says Herrera, who previously had found Beard a little dour, “that a New York winter is not the time to see the best in someone.”
When they got back to the city, Herrera was faced with a dilemma. He wanted them to sleep together without a condom, but Beard’s HIV undetectability wasn’t enough to ease his mind. Herrera started looking into going on PrEP.
“I felt an incredible loss of control, constrained,” says Herrera. “I thought previously I’d go on PrEP for every slut in New York City, then I found myself thinking of going on it for just one guy. I felt like I was being pulled into a big public-health trend, not to mention Gilead’s coy indirect marketing. Was it really the best thing for me?”
Beard would say to Herrera only that it was his body and his decision to make, but says he wasn’t comfortable having condomless sex, as a top, unless Truvada was involved.
Herrera went through the paperwork of getting on an Obamacare plan and going on PrEP. “I was a Latino immigrant who grew up without health care,” he says, “and finally I had a reason to be in a health structure and go to the doctor and get checked up every three months.” He took his first dose of PrEP with a huge can of Sixpoint beer and posted on Facebook a picture of the can alongside the Truvada bottle. One friend posted a frowny-face (perhaps thinking Herrera had HIV), but another wrote, “The future is now!” while yet another PrEP-taker said he liked to take his with a mimosa.
After ten days, once they were sure the Truvada had kicked in, Beard penetrated Herrera without a condom. “I was afraid I was going to hurt him,” says Beard. “I was dazed all day after,” Herrera replies. He smiles.
Homosexuality is separated from heterosexuality by the simple matter of whom one desires. And for 50 years, gay men have experienced an extreme series of turnabouts in their collective sexual psychology. The closets of the pre-Stonewall period gave way to the abandon of the ’70s, which was met with death and then shame and anxiety. And now? I ask Herrera how he felt about being on PrEP after what he called “the temper tantrum in my head” he’d experienced before starting the treatment—one in which it seemed like the various debates of the last half-century of gay sexuality were colliding, in miniature, as he made this one decision.
He pauses. “It feels like the future, like a new chapter,” he says. Then Herrera surprises us by starting to cry. After all, a powerful history of desire and dread intertwined is not easily undone. “I feel very proud because a lot of men have died for me to be able to do this,” he says.
Beard takes Herrera’s hand. “Leo thinks out loud,” he says. And then, to me, “Why should we continue punishing ourselves?”